Olgu Sunumu 178

A Case of Parastomal Hernia with Isolated Abdominal Wall Metastasis Of

Colorectal Cancer

Kolorektal Kanserin İzole Abdominal Duvar Metastazı ile Birlikte Olan Bir
Parastomal Herni Vakası

Mehmet Özyıldız, Murat Burç Yazıcıoğlu, Hamdi Taner Turgut, Ali Çiftci, Osman Civil, Selim Yigit Yildiz
Kocaeli Derince Training and Research Hospital, Department of General Surgery, Kocaeli

Dergiye Ulaşma Tarihi: 13.02.2017 Dergiye Kabul Tarihi: 01.04.2017 Doi: 10.5505/aot.2017.93685

ÖZET
Kolorektal kanserin en yaygın uzak ve lokal metastazı sırasıyla karaciğer ve küçük pelvise olur. Kolorektal
kanserin atipik lokalizasyonda izole metastazı, tanı anında ya da ameliyat sonrası izlem sürecinde görülebilir.
Cerrahi teknik, kanserin evresi ve hastalığın doğal seyri gibi birden fazla faktör bu sürecin hayati bileşenlerini
oluştursa bile bunların çoğunluğu tümör kolonizasyonu nedeniyle oluşur. Ancak tümör dökülmesine bağlı lokal
nüksle nadiren karşılaşılır ve cerrahi teknik eksikliği en çok suçlanan nedendir.
72 yaşındaki kadın hastada da tübülövillöz adenoma zemininde gelişen orta derecede diferansiye distal rektal
adenokarsinom (T1N0M0) için 2012 yılında geçirdiği APR (Abdominoperineal rezeksiyon) ameliyatından iki yıl
sonra Parastomal herni tespit edildi. Parastomal herni onarımı için operasyona alınan hastada karın duvarının
içinde şüpheli bir kitle palpe edildi. Kitle eksize edildi ve patolojik inceleme sonrası adenokarsinom olarak rapor
edildi. Yeniden operasyona alınan hastaya kolostomi ile çevresindeki cildin ve 15 cm kolon segmentinin
rezeksiyonunu içeren geniş rezeksiyon yapıldı. Biz, kolorektal kanserin izole metastazının izlem süresi boyunca
görülebileceğini, bu nedenle atipik lokalizasyondaki herhangi bir kitlenin dikkatli değerlendirilmesi gerektiğini
vurgulamayı amaçladık.
Anahtar kelimeler: kolorektal kanser, parastomal herni, adenokanser, izole batın duvarı metastazı, kolostomi

ABSTRACT
The most common distant and local metastasis of colorectal cancer is to liver and small pelvis respectively. The
isolated metastasis of colorectal cancer in the atypical localization can be seen at the time of diagnosis or at
postoperative follow-up period. Multiple factors such as surgical technique, stage of cancer, and natural history of
the disease are vital components of the process, however majority of them are due to tumor colonization. However
local recurrence due to tumor exfoliation rarely encountered, indetermination of surgical technique is the most
accused reason.
Parastomal hernia was detected in a 72 years old female patient two years after her APR (Abdominoperineal
resection) operation in 2012 for moderately differentiated distal rectal adenocarcinoma (T1N0M0) that developed
over tubulovillous adenoma. We found a suspicious mass within the abdominal wall closed to parastomal hernia
in the operation. The mass was excised and reported as adenocarcinoma after pathological examination. Re-
operation was planned and wide resection was performed with appropriate surgical margin including 15 cm of
colon loops with skin of colostomy site. We aimed to emphasize that isolated metastasis of colorectal cancer can
be seen during follow-up period so that any mass at atypical localization must be evaluated carefully.
Key words: Colorectal cancer, parastomal hernia, adenocarcinoma, isolated abdominal wall metastasis, colostomy

Introduction Colorectal cancer is diagnosed more than 1

million patients annually (2).
Colorectal carcinoma is the most common Twenty percent of colorectal cancer is
malignancy of the gastrointestinal tract, has presented with metastasis at initial diagnosis.
remained fairly constant over the past 20 years Cancer cells spread by faces through the
(1). Though the incidence is similar in men and intestinal lumen as normal physiological
women, it is the third most common cancer of transition (4), but for local and distant
male population however in female is the metastasis, transperitoneal spread, lymphatic
second most seen cancer around the world. spread, and hematogenous spread are the most
used ways (3). Cancer of the colon and rectum
are mostly metastases to regional lymph nodes,
Adress for correspondence: Murat Burç Yazıcıoğlu, Derince Eğitim ve Araştırma Hastanesi Genel Cerrahi Kliniği, Kocaeli - Türkiye
e-mail: mbyazicioglu@gmail.com
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 Olgu Sunumu 179

liver, lung, and peritoneum (4), it may present colostomy to identify the parastomal hernia but
with unusual metastasis such as palm a 40x30 mm mass was identified in the
metastasis, scalp metastasis, epididymis and abdominal wall adjusted to hernia sac, fascia
spermatic cord metastasis or isolated abdominal and distal colon. The mass was excised and
wall metastasis (5,6). Rarely colorectal reported as adenocarcinoma. When the patient’s
adenocarcinoma cells may be implanted into the CT was reevaluated postoperatively, we
anal fistula tract, in the hemorrhoidectomy scars recognized that metastatic mass was
or other various anal trauma sites (7). misdiagnosed and reported as only parastomal
Although reported incidence of hernia (Figure 1). An extended resection was
abdominal wall metastasis of colorectal cancer planned for the extension of resection. In the
was 0.5-1 %, autopsy studies have third operation systemic exploration was
demonstrated that the actual incidence of performed and found no sign of metastases. The
metastasis to abdominal wall or wound raised fascia, peritoneum and 15 cm segment of
up to 17% (8). There is general agreement that proximal colon with skin of colostomy site was
clinically obvious disease within the abdominal excised. Colostomy was revised from superior
wall is often a sign of disseminated intra- of first colostomy site. The defect in the
abdominal cancer (9). abdominal wall was closed with dual mesh.
In this study we presented a case of Pathological examination of the last specimen
parastomal hernia with isolated abdominal wall reported as no sign of cancer metastasis with
metastasis after two years of abdominoperineal negative surgical margin. The patient was
resection (APR) which was performed for discharged and redirected to oncology for
moderately differentiated distal rectal radiation and chemotherapy. In the follow up
adenocarcinoma that is developed on the base period of patient we found no sign of
of tubulovillous adenoma. intraabdominal sign of recurrence in the first
year of third operation. But unfortunately at the
Case end of the second year we found some signs of
intraabdominal metastasis of cancer.
A 72 years old female patient who had an
abdominoperineal resection (APR) operation in
2012 for moderately differentiated distal rectal
adenocarcinoma (T1N0M0) was admitted to
our polyclinic with swelling and pain around the
stoma after 2 years. Physical examination
revealed a parastomal hernia. Postoperative
abdominal computed tomography (CT) scan
was reported as normal in the first year. There
was no sign of recurrence. But in the second
year parastomal hernia was demonstrated in CT
scan but no comment about the mass we found Figure 1: CT view of parastomal hernia and mass
at operation. CEA and CA19-9 values were
normal before first and second operation (2.4
ng/ml, 7.59 ng/ml and 0.41 ng/ml, 5.65 ng/ml Discussion
respectively). The posteroanterior (PA) chest
X-ray and abdominal ultrasonography were Lymphatic or hematogenous seeding,
normal. There were no radiologic evidence of transperitoneal or direct metastasis are the ways
distant or local metastases. The patient was also of metastasis for colorectal cancer (10,11).
consulted to oncology department before the Colostomy site metastasis of adenocarcinoma
repairment of parastomal hernia. The patient especially after resection is rarely described
was planned for surgery with diagnosis of entity in the literature. Spread of colorectal
parastomal hernia, was given information about cancer by implantation was first reported by
the surgical technique and written informed Charles Ryall in 1907 (12). Colorectal cancer
consent form was obtained. At operation a spreading by implantation though rare, has been
transverse incision was made from inferior of described in hemorrhoidectomy wounds,
Adress for correspondence: Murat Burç Yazıcıoğlu, Derince Eğitim ve Araştırma Hastanesi Genel Cerrahi Kliniği, Kocaeli - Türkiye
e-mail: mbyazicioglu@gmail.com
Available at www.actaoncologicaturcica.com
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 Olgu Sunumu 180

colonoscopic biopsy sites, laparoscopic port procedure (19). There are many reports
sites, site of perianal injury, introduction of describing the implantation of tumor cells on
EEA stapler during anterior resection, and the trocar sites during laparoscopic procedures
Lonestar retractor insertion site after coloanal (20). Vukasin et al have reported this ratio as
anastomosis (12). 1.1% (10). Pezet et al have found cases of the
Cutaneous metastasis can be seen in the old abdominal wall metastasis after laparoscopic
operation scars due to changes in the surgery (21). Koea et al reported that metastasis
microscopic anatomy of the lymphatic were detected in 31 of 6463 patients, sixteen
channels, the changes in adhesion molecular patients developed tumor recurrence in a
profile or local immune response around the surgical incision which was used at the time of
scar. These are eligible sites for metastasis of the primary operation (abdominal incision,
the tumor cells (13). Evidence from clinical and colostomy site, or drain tract), 14 patients
experimental studies suggests that surgical recurred in an abdominal wall site distant from
trauma may promote tumor metastasis to the the incision, and one patient, opened with a
abdominal wall (14). The importance of midline incision, recurred in a subcostal
exfoliated cancer cells has been studied by incision previously used for an open
several authors (15). A mechanism more likely cholecystectomy (11). Hughes et al reported
responsible for abdominal wall metastasis is that only 13 (0.8 percent) of their series could
direct implantation of liberated cancer cells be specifically isolated to a surgical incision;
(13). It is thought that cancer cells may be furthermore, only 11 (0.6 percent) were at the
present in the peritoneal cavity before the midline incision (18). In our cases patient had a
surgical procedure or may be exfoliated during midline incision but metastatic mass was found
operative manipulation (12). Trauma to a tissue in stoma place with parastomal hernia. It is
has been known to enhance the growth of tumor unclear how the tumor cells were implanted to
cells either implanted into the peritoneal cavity abdominal wall in our case but we think that it
or delivery to the tissues via the circulation (14). was due to tumor cells seeding during first
The more evidence of promoting tumor cells in operation. In the literature it has been shown
the healing tissues of the laparotomy incision or that despite the fact that there is often a
the anastomosis were explained with relatively long interval between time of primary
hematogenous implantation (15). It is surgery and time of initial metastasis (2–49
considered much less likely as an explanation, months), prognosis with such abdominal wall
because the liver and lungs receive all of the metastatic disease is poor (14). In our study, the
venous drainage from the colon prior to the interval between time of primary surgery and
distribution to the rest of the body, it seems abdominal wall metastatic disease was 24
unlikely that the tumor would spread months and metastasis detection time was
hematogenously to the abdominal wall without compatible with literature. The patients who
pulmonary or hepatic involvement (16). In were operated and in follow-up period due to
clinical trials, the incidence of this entity have colorectal cancer, both physical examinations
been reported as 0.5-1%, but the autopsy studies as well as investigations of abdominal wall
have shown this ratio as 17% (4). Hughes et al. (skin - subcutaneous - intramuscular), trocar
found that 16 of 1,603 patients undergoing insertion site should be done for newly
curative resections had abdominal wall determined mass in such areas may be sign of
recurrence of their cancer, giving an incidence metastatic lesion. In addition to CEA, CA 19.9
of 1 percent (17). In a prospective study, Reilly monitoring, CT, MRI and PET-CT, or even tru-
et al reported that wound recurrences were seen cut biopsy could be performed to detect the
in 11 of 1711 patients (0.6%) (18). Koea et al mass in the abdominal wall, are guidance in
stated this ratio as 0.5% (11). This is our first determining the appropriate treatment (4).
case of detected abdominal metastasis in 280 Optimal treatment for patients with abdominal
colorectal cancer cases which were operated wall recurrence is surgical excision with
between 2009 and 2014 (0.36%). Tumor histologically clear margins. Complete surgical
recurrence due to the implantation sometimes resection of localized recurrence within the
occurs in the operating field, or in different abdominal wall, even when combined with en
places depending on the performed surgical bloc resection of intra-abdominal viscera, is
Adress for correspondence: Murat Burç Yazıcıoğlu, Derince Eğitim ve Araştırma Hastanesi Genel Cerrahi Kliniği, Kocaeli - Türkiye
e-mail: mbyazicioglu@gmail.com
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 Olgu Sunumu 181

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e-mail: mbyazicioglu@gmail.com
Available at www.actaoncologicaturcica.com
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